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Table 1.  

Recommendations for the Care of Cancer Survivors*

Table 2.  

General Symptoms of Cancer Survivors (Not Related to Specific Cancer or Treatment)

Table 3.  

Symptoms Most Common After Treatment of Rectal Cancer*


The Challenges of Colorectal Cancer Survivorship

  • Authors: Crystal S. Denlinger, MD; Andrea M. Barsevick, RN, PhD
  • CME Released: 9/21/2009
  • Valid for credit through: 9/21/2010, 11:59 PM EST
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Target Audience and Goal Statement

This activity is intended for primary care physicians, gastroenterologists, surgeons, radiation oncologists, and other physicians who care for patients with a history of colorectal cancer.

The goal of this activity is to describe common symptoms among survivors of colorectal cancer and the management of these patients.

Upon completion of this activity, participants will be able to:

  1. Analyze the prognosis of colorectal cancer (CRC)
  2. Identify the most common symptom among survivors of CRC
  3. Distinguish emotional concerns among survivors of CRC
  4. Describe long-term symptoms related to the treatment of CRC


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  • Crystal S. Denlinger, MD

    Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania


    Disclosure: Crystal S. Denlinger, MD, has disclosed that she has received research funding from Merrimack Pharmaceuticals for phase 1 clinical trials and from Genentech, Inc. for unrelated clinical trials.

  • Andrea M. Barsevick, RN, PhD

    Department of Nursing, Fox Chase Cancer Center, Philadelphia, Pennsylvania


    Disclosure: Andrea M. Barsevick, RN, PhD, has disclosed no relevant financial relationships.


  • Kerrin G. Robinson, MA

    Medical/Scientific Editor, Journal of the National Comprehensive Cancer Network


    Disclosure: Kerrin G. Robinson, MA, has disclosed no relevant financial relationships.

CME Author(s)

  • Charles P. Vega, MD, FAAFP

    Associate Professor; Residency Director, Department of Family Medicine, University of California, Irvine


    Disclosure: Charles P. Vega, MD, FAAFP, has disclosed no relevant financial relationships.

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The Challenges of Colorectal Cancer Survivorship: Lifestyle and Behavior Interventions


Lifestyle and Behavior Interventions

Although a careful assessment of QOL and treatment effects is an essential component of follow-up care for CRC, survivors are motivated to seek information on ways they can improve their outcomes, with informed choices especially important at treatment completion.[82] Cancer survivors present unique opportunities to implement primary, secondary, and tertiary prevention strategies that may result in multiple beneficial outcomes.[83] Many long-term survivors do not meet physical activity and dietary recommendations, and physicians can be powerful catalysts for promoting healthy behaviors.[84,85]

In a prospective observational study of survivors with stage III colon cancer treated with adjuvant chemotherapy, Meyerhardt et al.[86] showed a 47% improvement in disease-free survival in those who engaged in at least 18 metabolic equivalent task (MET)-hours per week of physical activity (≥ 6 hours per week of walking at an average pace) compared with inactive patients (< 3 MET-hours per week) at a median follow-up of 2.7 years. Relapse-free and overall survival also improved. This effect was independent of other prognostic factors, such as T stage, nodal status, treatment, performance status, age, or gender.[86]

In the Nurses' Health Study, more than 18 MET-hours per week of physical activity after a diagnosis of CRC was associated with reduced cancer-specific and overall mortalities. Women who increased their level of physical activity after diagnosis had a significant improvement in CRC-specific and overall mortality in both stage I/II and III disease.[87] Thus, physical activity may improve CRC-specific outcomes and prevent development of other morbidities, such as cardiovascular events and osteoporosis.[82] Further study of physical activity interventions are warranted to evaluate the true impact of exercise on cancer and other clinically relevant outcomes.

Body mass index (BMI) may predict outcome in CRC survivors.[88-90] Obese women had a significant increase in overall mortality but not in risk for colon cancer recurrence compared with normal-weight women at a median follow-up of 9.4 years after adjuvant chemotherapy, which was a trend not seen in men.[89] An evaluation of Dukes B and C colon cancer survivors who underwent adjuvant chemotherapy detected a 27% increase in the risk for colon cancer recurrence or death, with a 38% excess risk for colon cancer events and a 51% excess risk for death before colon cancer or second primary cancer, among very obese patients (BMI ≥ 35 kg/m[2]) at a median follow-up of 11.2 years. Overall survival was also worse among very obese and underweight survivors.[90] BMI and weight change after diagnosis in 1053 colon cancer survivors who underwent adjuvant chemotherapy was not associated with disease-free, relapse-free, or overall survival at a median follow-up of 5.3 years.[91] Obese men with rectal cancer undergoing treatment with adjuvant 5-FU and radiation were 61% more likely to experience a local recurrence and 23% more likely to have an overall cancer recurrence compared with normal-weight men. Increasing BMI was also associated with a higher rate of abdominoperitoneal resection.[92]

Visceral adiposity may be a better predictor of disease-free survival; a small cohort of 161 patients exhibiting a visceral-to-subcutaneous fat ratio of greater than 50% had a significantly lower cumulative disease-free survival rate than those with lower ratios.[93] Thus, survivors should be counseled about the importance of weight control and exercise, which may reduce the risk for cancer recurrence and improve overall health status.

The role of diet, nutritional supplements, and tobacco use in preventing cancer recurrence is often a topic of interest to cancer survivors. In a prospective observational study of dietary patterns in 1009 colon cancer survivors who underwent adjuvant chemotherapy, higher intake of a Western diet pattern (high in meat, fat, refined grains, and dessert) was associated with a more than 3-fold decrease in disease-free survival compared with those with the lowest intake of the same diet, and showed a similar decrease in relapse-free and overall survival. This association was independent of treatment group or other traditional prognostic factors. A prudent diet (high in fruits, vegetables, poultry, and fish) was not associated with cancer recurrence or mortality.[94] Additional prospective cohort studies have shown lower overall and CRC-specific mortality with consistent aspirin use and high circulating levels of 25-hydroxyvitamin D.[95,96] Lifetime tobacco use may also impact colon cancer recurrence, with trends toward lower disease-free survival in survivors with a 20 pack per year or greater smoking history compared with those who never smoked.[97] These studies provide hypotheses for further prospective investigation and possible interventions to improve outcomes in CRC survivors.